Published papers

We present 2 case reports of anti- N-methyl- d-aspartate receptor (NMDAR) encephalitis that was successfully treated via laparoscopic ovarian cystectomy. In both cases, resection of an ovarian teratoma resulted in eventual full recovery. Although adnexectomy has been reported for tumor resection in anti-NMDAR encephalitis, we chose ovarian cystectomy to preserve ovarian function. The efficacy of cystectomy is equivalent to that of adnexectomy. This suggests that ovarian adnexectomy may not be necessary in anti-NMDAR encephalitis with ovarian teratoma. © 2011 AAGL.

© 2018 Elsevier Ltd Background: The differentiation of progressive supranuclear palsy-parkinsonism (PSP-P) from Parkinson's disease (PD) remains a major clinical challenge. Objectives: To evaluate the diagnostic potential of observer-independent assessments of microstructural integrity within infratentorial brain regions to differentiate PSP-Richardson's syndrome (PSP-RS), PSP-P and PD. Methods: 3T MRI parameters of mean diffusivity, fractional anisotropy, grey and white matter volumes from patients with PSP-RS (n = 12), PSP-P (n = 12) and mean disease duration of 2.4 ± 1.7 years were compared with PD patients (n = 20) and healthy controls (n = 23) by using statistical parametric mapping and the spatially unbiased infratentorial template. Subsequently MRI measurements of the dentatorubrothalamic tract were determined observer-independently by a validated probabilistic infratentorial atlas. The impairment of gait and postural stability was evaluated by a sum-score derived from the Unified Parkinson Disease Rating Scale. Results: Significant mean diffusivity increases, fractional anisotropy decreases and corresponding volume loss were localized in mesencephalic tegmentum, superior cerebellar peduncle, decussation of superior cerebellar peduncle and dentate nucleus in PSP-RS and PSP-P compared to PD and healthy controls. Altered microstructural integrity of the dentatorubrothalamic tract in PSP-RS was significantly more pronounced compared to PSP-P and correlated significantly with the gait and postural stability sum-score. Linear discriminant analysis identified diffusion tensor imaging measures of the dentatorubrothalamic tract and the gait and postural stability sum-score to classify correctly 95.5% of PRP-RS, PSP-P and PD patients. Conclusions: Observer-independent analysis of microstructural integrity within the dentatorubrothalamic tract in combination with assessments of gait and postural stability differentiate PSP-P from PSP-RS and PD in early to moderately advanced stages.

Patients with limbic encephalitis usually present with rapidly progressive short-term memory deficits, psychiatric symptoms, and seizures. The recent concept of limbic encephalitis has been expanded. Especially, various types of autoimmune limbic encephalitis are associated with autoantibodies of intracellular or cell membrane antigens. Sine autoimmune limbic encephalitis is also associated with some types of tumors, it has also an aspect of paraneoplastic syndrome. Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a new category of treatment-responsive limbic encephalitis associated with anti-NMDAR antibodies, which is the most frequent autoantibody to cell membrane antigen. The autoantibodies are detected in the CSF and serum of young women with ovarian teratoma, who typically develop schizophrenia-like psychiatric symptoms. There is a highly characteristics syndrome evolving in 5 stages; the prodromal, psychotic, unresponsive, hyperkinetic, and gradual recovery phases. The hyperkinetic phase is the most prolonged and crucial. This disorder is usually severe and can be fatal, but it is potentially reversible. Although the pathogenesis remains unclear, this disorder is considered to be the autoantibody-mediated encephalitis. This review focuses in the recent concept of limbic encephalitis and clinical characteristics of anti-NMDA receptor encephalitis. © 2013 The Japan Society for Clinical Immunology.

REM sleep behavior disorder (RBD) is known to be observed more frequently in patients with an a-synucleinopathy such as Parkinson's disease (PD) than in the general population. The precise prevalence of RBD in Japanese PD patients is not known. Therefore, we investigated the prevalence and the clinical characteristics of patients with RBD in a large population of Japanese patients with PD. We investigated various clinical features and employed the Japanese version of the RBD screening questionnaire on 469 non-demented Japanese PD patients in this multicenter study. Probable or possible RBD was detected in 146 patients (31.1%) and was significantly associated with longer PD duration, higher Hoehn and Yahr stage, higher Unified Parkinson's Disease Rating Scale part III subscale (7 items), more motor fluctuations, and a higher levodopa-equivalent daily dose (p<0.01). As to the major autonomic dysfunctions, severe constipation was significantly more frequent in PD patients with RBD than in those without it (p<0.01). The RBD symptoms of 53 patients (39.0%) preceded the onset of PD motor symptoms. The median interval from the onset of RBD symptoms to PD motor symptoms was 17.5 years, and 3 patients had intervals of over 50 years. This large-scale multicenter study revealed that RBD is a frequent nonmotor symptom in Japanese patients with PD, which may precede the onset of motor symptoms. Moreover, RBD that increases with the duration and severity of PD may be associated with autonomic dysfunction. © Springer-Verlag 2012.

Mitochondrial dysfunction has been implicated in the pathogenesis of both idiopathic and familial Parkinson's disease (PD). Dopamine neurons in the substantia nigra exhibit autonomous pacemaking activity to maintain an optimal dopamine concentration in the striatum, resulting in the activation of energy metabolism. ATP production in neuronal cells is dependent on mitochondrial glucose oxidation, and reactive oxygen species (ROS) production associated with neuronal activation might be a major cause of mitochondrial damage in dopamine neurons. Alpha-synuclein, a major component of Lewy bodies, induces mitochondrial damage, and several genes responsible for familial PD encode molecules necessary for normal mitochondrial function. In addition, the auto-oxidation of dopamine produces dopamine quoinone and ROS. Astroglia provide neurons with lactate produced from glucose via glycolysis in response to neuronal activation. The co-activation of the pentose-phosphate pathway (PPP), a shunt pathway of glycolysis, in astroglia plays a pivotal role in protecting neurons against ROS with glutathione peroxidase and the reduced form of glutathione (GSH). In addition to the allosteric regulation of the PPP, which is associated with the activation of glycolysis, the PPP in astroglia can also be activated by ROS through the Kelch-like enoyl-CoA hydratase-associated protein 1 (KeapD/nuclear factor-erythroid 2 p45 subunit-related factor 2 (Nrf2) system. A rate-limiting enzyme of the PPP, glucose-6-phosphate dehydrogenase (G6PDH), is transcriptionally regulated by the Keapl/Nrf2 system, which is a master regulator of phase 2 detoxifying enzymes. ROS is thought to modify the thiol residue of Keapl and to facilitate Nrf2 dissociation from Keapl. Thereafter, Nrf2 translocates into the nucleus where it induces the transcription of G6PDH. The pharmacological activation of the Keapl/Nrf2 PPP in astroglia may provide a novel strategy for preventing the onset and progression of PD.

Objective: The aim of this work was to investigate the prevalence of camptocormia and the clinical characteristics of patients with camptocormia in a large population of PD patients. Background: Although camptocormia has been recognized as a prominent phenomenon in PD, the previous epidemiological reports were limited, especially in terms of sample size. Methods:: We evaluated 531 PD patients (disease duration: 7.0 ± 5.5 years, mean ± standard deviation). We examined their clinical features and the prevalence of camptocormia. Results: Camptocormia was detected in 22 patients (4.1%) and found in patients who were older and had more severe motor symptoms and a higher levodopa (L-dopa) dose (P < 0.05), compared to the patients without camptocormia. Patients with camptocormia showed significantly higher frequencies of autonomic symptoms, such as constipation and urinary incontinence (P < 0.05). Conclusions: Camptocormia is uncommon in PD and is associated with disease severity, higher L-dopa dose and higher frequencies of autonomic symptoms. © 2011 Movement Disorder Society.

Objective: This multicenter cross-sectional study aimed to investigate the clinical features and varieties of non-motor fluctuation in Parkinson's disease (PD). Methods: To identify motor and non-motor fluctuation, we employed the wearing-off questionnaire of 19 symptoms (WOQ-19) in 464 PD patients. We compared the frequency of levodopa-related fluctuation as identified by the WOQ-19 with recognition by neurologists. We compared patients with both motor and non-motor fluctuations with those who only had motor fluctuations. Non-motor fluctuations were separated into psychiatric, autonomic, and sensory categories for further analysis. Results: The patients' average age was 70.8 ± 8.4 years (mean ± SD) and disease duration was 6.6 ± 5.0 years. The frequency of motor fluctuations was 69% and for non-motor fluctuation 40%. Fifty-three percent of patients with motor fluctuations also had non-motor fluctuations, whereas 93% of patients with non-motor fluctuations also had motor fluctuations. The WOQ-19 showed a sensitivity of 82% but a specificity of only 40%. The patients with both non-motor and motor fluctuations exhibited more severe motor symptoms, more non-motor symptoms and higher levodopa daily doses (p < 0.05). Patients had significantly higher fluctuation rates if they had psychiatric (49%) and sensory (45%) symptoms than patients with autonomic symptoms (32%, p < 0.01). Forty-eight percent of patients with non-motor fluctuations exhibited more than one type of non-motor fluctuation. Conclusion: Forty percent of PD patients presented with non-motor fluctuations, and almost half of these exhibited more than one type. Appropriate recognition of levodopa-related fluctuations, both motor and non-motor, can lead to treatment modifications in PD patients. © 2012 Elsevier Ltd.